<div>
    <form method="post">
        <ul>
            <li>
                <label class="user_label">
                    Patent Office
                    <abbr title="Required" class="user_required">*</abbr>
                </label>
                <div>
                    <select class="form-control user_select_box" style="width: 300px">
                        <option value selected="selected" style="text-align: center">-</option>
                        <option value="europe">Europe</option>
                        <option value="spain">Spain</option>
                    </select>
                </div>
            </li>
            <li>
                <label class="user_label">
                    Status
                    <abbr title="Required" class="user_required">*</abbr>
                </label>
                <div>
                    <label>
                        <input type="radio" value="I" name="patentStatus" checked>
                        Patent Issued
                        <input type="radio" value="P" name="patentStatus">
                        Patent Pending
                    </label>
                </div>
            </li>
            <li>
                <label class="user_label">
                    Patent/Application Number
                    <abbr title="Required" class="user_required">*</abbr>
                </label>
                <div>
                    <input type="text" required maxlength="100" size="32" class="form-control">
                </div>
            </li>
            <li>
                <label class="user_label">
                    Patent Title
                    <abbr title="Required" class="user_required">*</abbr>
                </label>
                <div>
                    <input type="text" required maxlength="100" size="32" class="form-control">
                </div>
            </li>
            <li>
                <label class="user_label">
                    Inventor(s)
                    <abbr title="Required" class="user_required">*</abbr>
                </label>
                <div>
                    <input type="text" maxlength="100" size="32" class="form-control">
                </div>
                <div class="index_note">Drag to reorder contributors.</div>
            </li>
            <li>
                <label class="user_label">Issue/Filing Date</label>
                <div>
                    <select class="form-control user_select_box">
                        <option value selected="selected" style="text-align: center">Month..</option>
                        <option value="1">January</option>
                        <option value="2">February</option>
                        <option value="3">March</option>
                        <option value="4">April</option>
                        <option value="5">May</option>
                        <option value="6">June</option>
                        <option value="7">July</option>
                        <option value="8">August</option>
                        <option value="9">September</option>
                        <option value="10">October</option>
                        <option value="11">November</option>
                        <option value="12">December</option>
                    </select>
                    <select class="form-control user_select_box">
                        <option value selected="selected" style="text-align: center">Day..</option>
                        <?php
                        for($i = 1; $i <= 31; $i++){
                            echo '<option value="'.$i.'" style="text-align: center">'.$i.'</option>';
                        }
                        ?>
                    </select>
                    <select class="form-control user_select_box">
                        <option value selected="selected" style="text-align: center">Year..</option>
                        <?php
                        for($i = 2014; $i >= 1900; $i--){
                            echo '<option value="'.$i.'" style="text-align: center">'.$i.'</option>';
                        }
                        ?>
                    </select>
                </div>
            </li>
            <li>
                <label class="user_label">
                    Patent URL
                </label>
                <div>
                    <input type="text" maxlength="100" size="32" class="form-control">
                </div>
            </li>
            <li>
                <label class="user_label">
                    Description
                </label>
                <div>
                    <textarea rows="6" cols="110" class="user_edit_text_area" style="max-width: 100%"></textarea>
                </div>
            </li>
            <p>
                <input name="submit" type="submit" class="btn btn-primary" value="Save">
                <button type="button" class="btn btn-default">Cancel</button>
            </p>
        </ul>
    </form>
</div>